Application in Acquiring Specially Adapted Housing or Special Home Adaptation Grant (Title 38 U.S.C. Section 2101(a) or 2101(b))

10/26/2021

https://eauth.va.gov/lgyhub/SAH/web/secured/grants/statusHistory.jspx
OMB Approved No. 2900-0132

Reference Number: 216542

Department of Veterans Affairs

VETERAN'S APPLICATION IN ACQUIRING SPECIALLY ADAPTED HOUSING OR
SPECIAL HOME ADAPTATION GRANT
(Title 38 U.S.C. Section 2101(a) or 2101(b))
Privacy Act Notice: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38,CFR 1.576 for routine uses (for
example: Authorizing release of information to Congress when requested for statistical purposes) identified in the VA system of records,55VA26, Loan Guaranty Home, Condominium and
Manufactured Home Loan Applicant Records, Specially Adapted Housing Applicant Records, and Vendee Loan Applicant Records - VA, published in the Federal Register. Your obligation to respond
is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38, CFR 3.809. The VA will not deny an individual
benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect.
Respondent Burden: We need this information to determine or verify your eligibility for a specially adapted housing or special home adaptation grant. Title 38, U.S.C.2101(a) or 2101(b) allows us to
ask for this information. We estimate that you will need an average of 10 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of
information unless a valid OMB control number is displayed. Valid 0MB control numbers can be located on the 0MB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call
1-800-827-1000 to get information on where to send comments or suggestions about this form.

1. FIRST NAME - MIDDLE INITIAL - LAST NAME OF VETERAN

2. VETERAN'S SOCIAL SECURITY NO.

Johnny F Doe

000-00-0000

4. DATE OF BIRTH

5. E-MAIL ADDRESS

05/19/1900

JohnDoe@gmail.net

3. VA FILE /CLAIM NUMBER

6. ADDRESS (Number and street or rural route, city or P.O., State and ZIP Code)
2123 Min St.
Northern GA, 12345-2743

7. TELEPHONE NUMBERS OF VETERAN (Include Area Code)
A. DAYTIME

B. EVENING

C. CELL
(999) 366-0000

8. HAVE YOU MADE A PREVIOUS APPLICATION FOR SPECIALLY ADAPTED HOUSING?(If "YES," give date and place)
Yes No Unknown
9. HAVE YOU MADE PREVIOUS APPLICATION FOR HOME IMPROVEMENT AND STRUCTURAL ALTERATION GRANT?(If "YES," give date and place)
Yes No Unknown
10. ARE YOU CONFINED TO A NURSING HOME OR MEDICAL CARE FACILITY? (If "YES," give name and address of facility)
Yes No
11. REMARKS
Yes , I would like to know do I get VA assistance for home improvement. I bought 15 solar panels and 3 generac for home improvement. Is there any assistance I can get for my home.

CERTIFICATION
I am applying for assistance in acquiring specially adapted housing or special home adaptation grant because of the nature of my service-connected disability. I understand that there are medical and
economic features yet to be considered before I am eligible for this benefit, and that I will be notified of the action taken on this application as soon as possible.

12A. SIGNATURE OF VETERAN (Sign full name)

Electronic Application - Validated by LGY (Signature not required)

12B. DATE SIGNED
10/15/2021

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact, knowing it to be false.
VA Form 26-4555

https://eauth.va.gov/lgyhub/SAH/web/secured/grants/statusHistory.jspx

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